Acute

Viral
Hepatitis
Dr.Hasibi

Etiology
Major

agents:

HAV
HBV

HGV

HCV

TTV

HDV
HEV

HFV

Etiology
Minor

agents:

EBV,CMV
HSV,VZV
Rubella,Measles
Coxsackie

B
Adenovirus

Transmission
HAV HBV HCV

HDV HE
V

Fecal-oral

Percutan.

Perinatal

Sexual

Epidemiology
HAV:fecal-oral
HEV:fecal-oral
Rarely bloodborne
HBV:percutaneous contact
Mucous membrane contact
Sexual contact
Perinatal:third trimester and
2 months postpartum
HDV : like HBV

Epidemiology

HCV:
Percutaneous transmission
Transfusion(0.1 %),needle stick(1.8
%)
Mucousal transmission (rare)
Sexual transmission is
rare(monogamy) Perinatal
transmission is uncommon
(HIV coinfection,less than 5 % )

Sexual transmission of
HCV
Multiple sexual partner
HIV and STD
Anal sex
Open sore
Sex during menstruation

Pathology
Infiltration

of mononuclear

cells
Hepatic cells necrosis
Kupfer cells hyperplasia
Variable degrees of cholestasis
In more severe cases;
Bridging necrosis

Clinical Stages
Incubation

period
Prodromal (preicteric)
phase
Icteric phase
convalescence

Variation in
staging

Asymptomatic
Anicteric
Fulminant
Chronic

Incubation
Period

HAV:15-45

days(30)
HBV: 30-180 days(60-90)
HCV: 15-160 days(50)
HDV: 30180 days(60-90)
HEV: 14-60 days(40)

Incubation
Period

Considerable

overlap
Asymptomatic period
Viral replication&
Shedding

Preicteric Phase
Systemic &nonspecific symptoms
Flue like &Dyspepsia:
Fever,sore
throat,cough,headache
Fever,anorexia,malaise,nausea
Vomiting,abdominal pain
Duration : 1-2 weeks

Icteric Phase
Clinical

jaundice
Dark urine:1-5 days before
jaundice
Patient may feel better
Resolution of fever
pruritus

Icter

Icter

Icter

Icteric Phase
Liver

is enlarged,tender
Cervical adenopathy(10-20%)
Splenomegaly(10-20%)
Fever is absent
Venopuncture site
Encephalopathy :Irritability
Letargy,confusion

Convalescence
Resolution

of symptoms
Liver is enlarged
Pruritus
Complete recovery:
1-2 months A,E
3-4 months B,C (3/4)

Laboratory
Findings
CBC:leukopenia,lymphocytos

is
Atypical lymphocyte,
Normal Hb;except
hemorrage
Normal platelet;except DIC
ESR is normal

Laboratory
Findings
Serum bilirubin:5-20 mg/dl

Direct

bil =indirect bil

SGOT,SGPT=400-4000 iu
Alk.phosphatase :mild elevation
PT is usually normal:in severe
hepatitis,PT is prolonged
Hypoglycemia

 Ig

Serologic
Diagnosis

M anti-HAV
HBs Ag and Ig M antiHBc
HCV Ab,HCV RNA PCR
anti-HDV
anti-HEV

Complications
Hepatitis

A:Relapsing

hepatitis
Cholestatic hepatitis
Hepatitis B:serum sickness
Chronicity:HBV,HCV,HDV
fulminancy:HAV,HBV,HDV,
HEV

Progression of Acute to
chronic Hepatitis
Lack of resolution of symptoms
(WL,fatigue,anorexia,hepatomegaly
)
Failure of Bil. ,LFT,Glu to normal
(Within 6-12m)
Persistence HBs Ag beyond 6 m or
HBe Ag beyond 3 m
Presence of bridging or
multilobular necrosis

Diferential
Diagnosis
Viral hepatitis by minor agent

Gram

negative Sepsis
Cholangitis,cholecystitis
Flare up chronic hepatitis
Drug-related hepatitis
Ischemic hepatitis

Management
Indication

of admission:
Bilirubin>20 mg/dl
Hypoglycemia
Abnormal PT
Hypoalbuminemia

Management
Indication

of admission :
Poor oral intake
Mental change,letargy
Low compliance
Other chronic disease

Management
CBR

isnot mandatory
Restriction activity
No special diet
&Therapy(HCV ? )
Drug &Alcohol avoidance
Isolation isnot necessary
except special cases

Monitoring
Regular

physical exam
Liver size,mental
state,icter
Check of LFT,BS,PT,BIL
Serial check of HBs Ag
and HCV Ab

Prevention
Hand

washing,hygiene
Universal percaution
No

sharing of personal items

(razor,toothbrush,nail
clipper)
Sexual barrier

prevention
HAV:
Pre-exposure

prophylaxis:
Vaccine ,SIG:0.02 cc/kg
Post-exposure prophylaxis:
SIG:0.02 cc/kg ;For day care
centers,family members
Vaccine ?

Prevention
HBV:
Pre-exposure

prophylaxis:
Vaccine :months 0,1,6
Booster isnot recommended
Post-exposure prophylaxis:
HBIG:0.06 cc/kg and complete
course of vaccine

Prevention
Post-exposure

prophylaxis in
vaccinated person :
Responder:No treatment

Nonresponder:HBIG+Vaccine(3)
OR
HBIG (2) in one month
Response:anti-HBs>10miu/ml

Prevention
Ab

response unknown:
Check anti-HBs;
If adequate:no
treatment
If inadequate:HBIG(1)
+
vaccine(1)

Post exposure
prophylaxis

HCV

:no treatment
HEV: no treatment